Zusammenfassung
Hintergrund
Inkompatibilitäten von Medikamenten können Ausfällungsreaktionen bedingen und zu transienten Lungenembolien führen. Kürzlich wurde über die Unverträglichkeit von Piritramid mit Cephalosporinen berichtet. In der vorliegenden Studie wurde der Frage nachgegangen, ob die Präzipitatbildung von der Piritramidkonzentration oder dem pH der Lösung abhängig ist.
Methoden
Piritramid wurde in physiologischer Kochsalzlösung verdünnt und die jeweilige Testkonzentration mit Cefazolin gemischt. Präzipitatbildung wurde als das Vorhandensein einer weißlichen, trüben Ausfällung definiert.
Ergebnisse
Die Piritramidkonzentrationen 5; 3,75 und 3 mg/ml zeigten eine Ausfällungsreaktion, während diese bei 1,875; 1 und 0,5 mg/ml nicht auftrat. Um die Möglichkeit auszuschließen, dass eine pH-Wert-Änderung dafür verantwortlich ist, wurden die pH-Werte der getesteten Verdünnungen bestimmt. Die Mittelwerte der Konzentrationen 5; 3,75; 3; 1,875 und 1 mg/ml unterschieden sich nicht voneinander, während jedoch der pH-Wert der 0,5-mg/ml-Lösung signifikant abwich.
Schlussfolgerungen
Die Präzipitatbildung ist von der Piritramidkonzentration abhängig. Eine Korrelation der Ausfällungsreaktion mit den pH-Werten der getesteten Piritramidverdünnungen konnte nicht festgestellt werden. Bei zeitnaher Verabreichung von Cephalosporinen und Piritramid sollten Patienten aus Sicherheitsgründen eine Piritramidkonzentration von 1 mg/ml erhalten.
Abstract
Background
Drug incompatibility might lead to precipitation with subsequent serious complications, such as transient pulmonary embolism. Recently, incompatibility of the opioid piritramide with cephalosporin antibiotics was described. As both drugs are frequently administered in a perioperative setting, the present study addressed the question whether the precipitation effect depends on the piritramide concentration or on the pH of the solution. Moreover, it was tested whether the precipitate reversibly dissolves in a physiological saline solution.
Methods
Piritramide was diluted to the final test concentrations in 0.9 % sodium chloride solution. Precipitation tests were performed by combining 1 ml of the respective piritramide dilution with 1 ml of cefazolin (20 mg/ml) in a syringe. Precipitation was detected by visual inspection as an opaque whitish appearance of the mixture. Each concentration was tested 5 times. The pH values of the tested piritramide concentrations were determined using a 3-point calibrated pH meter. The precipitate formed in 1 ml of cefazolin (20 mg/ml) and 1 ml of piritramide (5 mg/ml) was diluted in 3 ml physiological saline.
Results
The piritramide concentrations 5 mg/ml, 3.75 mg/ml and 3 mg/ml precipitated in the presence of cefazolin (20 mg/ml), while the concentrations 1.875 mg/ml, 1 mg/ml and 0.5 mg/ml did not produce a precipitate. To exclude the possibility that changes in pH of the tested dilutions might be responsible for these findings, the pH values of the piritramide dilutions were measured. The mean pH values of the concentrations 5 mg/ml, 3.75 mg/ml, 3 mg/ml, 1.875 mg/ml and 1 mg/ml did not differ significantly (pH 3.89 ± 0.004, n = 26, tested by ANOVA). However, the mean pH of 0.5 mg/ml was significantly different from the other tested dilutions (pH 3.98 ± 0.02, n = 6; p< 0.01 by ANOVA). After diluting the precipitate of piritramide and cefazolin in physiological saline the whitish precipitate completely dissolved and the resulting solution became clear (n = 5).
Conclusion
The results imply a concentration dependence of the precipitation with cefazolin, while a correlation with pH changes could not be detected. In cases of co-administration of cephalosporins and piritramide, a piritramide concentration of 1 mg/ml seems to be safe and does not form a precipitate. As the precipitate could be reversed by diluting in saline solution it is most likely that a proton switch between the carboxylic acid moiety of cefazolin and the amino group of piritramide causes the precipitation.
Literatur
Dieterich M, Müller-Jordan K, Stubert J et al (2012) Pain management after cesarean: a randomized controlled trial of oxycodone versus intravenous piritramide. Arch Gynecol Obstet 286:859–865
Adamek S, Matouskova O, Pafko P et al (2010) The role of diclofenac and piritramide in the management of acute postoperative pain in hernioplasty. Bratisl Lek Listy 111:616–618
Jage J, Laufenberg-Feldmann R, Heid F (2008) Drugs for postoperative analgesia: routine and new aspects: part 2: opioids, ketamine and gabapentinoids. Anaesthesist 57:491–498
Adams HA, Saatweber P, Schmitz CS et al (2002) Postoperative pain management in orthopaedic patients: no differences in pain score, but improved stress control by epidural anaesthesia. Eur J Anaesthesiol 19:658–665
Abdulla S, Eckhardt R, Netter U et al (2012) Randomized, double-blind, placebo-controlled study to assess the efficacy of nonopioid analgesics on pain following arthroscopic knee surgery. Pain Res Treat 2012:305821
Weber WP, Marti WR, Zwahlen M et al (2008) The timing of surgical antimicrobial prophylaxis. Ann Surg 247:918–926
Spicher I, Beer GM, Minder J et al (2003) Perioperative antibiotic prophylaxis at the Clinic of Reconstructive Surgery of the Zurich University Hospital. Swiss Surg 9:9–14
Eckle VS, Heim E, Hahn M et al (2013) Incompatibility of piritramide with cephalosporins. Ann Pharmacother 47:426–427
Khan S, Stannard N, Greijn J (2011) Precipitation of thiopental with muscle relaxants: a potential hazard. JRSM Short Rep 2:58
Njoku D, Lenox WC (1995) Use care when injecting rocuronium and thiopental for rapid sequence induction and tracheal intubation. Anesthesiology 83:222
Taniguchi T, Yamamoto K, Kobayashi T (1998) Precipitate formed by thiopentone and vecuronium causes pulmonary embolism. Can J Anaesth 45:347–351
Ng HP, Koh KF (2002) Precipitation of protamine by cefazolin. Anesth Analg 95:785
Foinard A, Décaudin B, Barthélémy C et al (2012) Impact of physical incompatibility on drug mass flow rates: example of furosemide-midazolam incompatibility. Ann Intensive Care 2:28
Foinard A, Décaudin B, Barthélémy C et al (2013) The impact of multilumen infusion devices on the occurrence of known physical drug incompatibility: a controlled in vitro study. Anesth Analg 116:101–106
Newton DW (2009) Drug incompatibility chemistry. Am J Health Syst Pharm 66:348–357
Danksagung
Die Autoren bedanken sich bei Frau C. Holt für die fotografische Unterstützung bei Abb. 1 und für das Gegenlesen des Manuskriptes.
Einhaltung ethischer Richtlinien
Interessenkonflikt. V.-S. Eckle und C. Grasshoff geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Eckle, VS., Grasshoff, C. Präzipitation von Piritramid und Cefazolin. Anaesthesist 62, 898–901 (2013). https://doi.org/10.1007/s00101-013-2246-y
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00101-013-2246-y